21 November 2012

Patience is a Virtue...

I'm a bit worried about the way things are developing regarding the Savita Hallapanavar story. Initially I was troubled by how pro-choicers seemed to be spinning a story markedly devoid of firm facts in such a way that Savita Hallapanavar had been crowned in death as a martyr to political cowardice and Ireland's refusal to legislate for abortion; it's been the usual sheep who bleat about 'evidence-based reasoning' who've seemed most keen to shun evidence and reasoning in their eagerness to make spurious links on this one, dogmatically asserting that Savita died because of Catholicism and Ireland's abortion laws.

Now, though, I'm seriously bothered that pro-lifers might be so desperate to believe that her death had nothing to do with abortion that they leap on anything that supports their views.

This letter, from a Doctor J Clair, takes issue with how he believes the honour of the Irish medical profession has been impugned over the circumstances of Savita's death, which he thinks almost certainly had nothing to do with abortion:

"It appears to me that the problem was an unforeseen ESBL infection rather than an issue of obstetric mishandling.

In my experience of over 30 years with clinical antibiotic use, ESBL antibiotic resistance is by far the most worrying development that I have experienced.

The insult to the Irish medical service is added to by the suggestion that the Indian Embassy is upset with the lack of abortion services in Ireland.

This insult is further compounded by the fact the Indian subcontinent has played a major role in the spread of ESBL positive organisms."

Now, I'm not going to say that this is implausible, and we have heard of similarly antibiotic-resistant viruses making their way here from India and thereabouts, but I don't see that there's any way Dr Clair could credibly identify this as the cause of Savita's deaths without having seen her charts, such that this, surely, is conjecture. If, on the other hand, he's saying this because he's seen her charts, then wouldn't this constitute some kind of breach of confidentiality?

"Mrs Halappanavar died of an antibiotic-resistant infection, specifically e.coli ESBL. She did not die from an abortion, from being denied an abortion, from Catholic teaching or from a confused legal system in Ireland.

[...]

Getting information has been like pulling teeth. I cannot mention names or attribute their comments even to ‘a doctor/nurse/paramedic at x/y/z hospital/surgery/healthcare trust’. I can’t even mention the area they live and practice; they are frightened of being traced and found out. That could have been put down to the fear that they were passing on hearsay and gossip – but the same story has come from multiple sources. It passes the usual tests of corroboration."

Mark's a decent, intelligent, and level-headed bloke who will have posted this in absolute sincerity and with the best will in the world, and though I don't know Ruari at all, I have no reason to doubt his integrity, but no matter he believes or why, I think it's deeply imprudent to push this line. Indeed, I think it's imprudent even to embrace this thesis.

We know precious little about what happened in Galway: we know that Savita had a miscarriage and died of an infection some days later; we know that she was started on antibiotics at some point, though we don't know when as her husband Praveen has contradicted himself on this point and the hospital has given a third possible date for this; we know that Praveen's timeline of events seems to be utterly irreconcilable with one purporting to come from the hospital.

That's about all that we can say for certain. We can't make assertions about what happened. We can really only point to the discrepancies and ask questions. Just as pro-choicers shouldn't be jumping to the conclusion that Savita died because she was denied a termination of pregnancy or because of any supposed uncertainty in Irish law, neither should pro-lifers be asserting that she definitely didn't die for those reasons, and grabbing at the claim that she died because of some subcontinental superbug.

It may yet turn out that pro-lifers indeed have blood on their hands on this issue, but we just don't know.

We have to wait until the investigations do their work, and yes, I know it looks as though the HSE one looks fatally hamstrung becausePraveen refuses to cooperate with the investigation -- not allowing it access to Savita's medical records -- because he says it won't be independent and because he says "the HSE are the ones who messed up Savita's care", but still, we have to wait.

Any assertions on this issue must be either sheer conjecture or based on information most definitely absent from the public domain. We can ask questions -- and let's face it, we ought to, as our journalists aren't exactly doing their job on that front -- but given how little we know, there aren't that many questions that legitimately fall within the remit of the general public. Certainly, we shouldn't assert anything. Things are mysterious enough, and no matter how good our intentions might be, it is, I think, deeply irresponsible to add anything to the current confusion.

We need facts, not wishful thinking, and information, not conspiracy theories.

7 comments:

Lynda
said...

What we do know is that the case has nothing to do with abortion (the intentional, deliberate act of killing a baby in utero). The case concerns medical treatment, and whether what was given was the best possible. There may or may not have been medical negligence. Sometimes, people with acute infections cannot be saved despite the best possible medical treatment being given. Ireland is a world-renowned centre of excellence in obstetrics and maternal medicine, made possible by the high standard of ethics in the medical and nursing professions, which put the care and safety of the lives of their mother and baby patients first. As was recently confirmed by an International Symposium on Maternal Healthcare held in Dublin, abortion is not medicine, it is never necessary to save a mother's life. Ireland is the safest country in the world for mothers and babies for about 30 years, because medicine not abortion is practised here. It is the MO of the abortion industry, it's lobby and supporters to mislead people by deceitfully conflating abortion with medicine, which in certain circumstances where a mother's life is endangered may result in the unintended, undesired but unavoidable death of the baby. The latter is NOT abortion. By using the term "abortion" for those situations when medicine (moral and legal) may result the death of the baby, pro-abortionists aim to legalise abortion ( the intentional, deliberate killing of the baby in utero. It is with such lies they got abortion (the murder of innocent babies in utero) made legal in other countries. Don't fall for the lies. Don't use their purposely-misleading language. If the best maternal medicine were not practised in Ireland, there would be a much higher rate of maternal death, not the tiny one we have. Countries that practise the abomination of abortion have much higher maternal death rates, and the official figures don't include many where the cause is abortion, where the fact that abortion caused the haemorrhage, etc. that killed the woman is omitted. Abortion not only deliberately kills an innocent defenceless child, but kills many women (in India, 20,000 per year). Many women are permanently mutilated, rendered infertile, and countless more, psychologically traumatised by abortion. If Ireland wants to continue to protect women's lives (as well as their babies), it will refuse to legalise abortion.

We do not know each other, I can confirm. Why, you do not even know how to spell my name correctly (It's Ruari. Short for the Argyll Gaelic name but that's what I do to make things easier for the English...)

I was not aware of Dr Clair's letter in the Examiner until Mark Lambert drew my attention to it on Wednesday morning, after I had semi-prepared the information that ultimately appeared on his blog as a guest post. He will be able to confirm that I had been trying to confirm the particular strain of antibiotic-resistant bacterium for some days. I had not told anyone what I had been advised it was, in order to avoid even being seen to be bringing undue influence to bear.

I was told it was an antibiotic-resistant infection last Friday and got the name of e.coli ESBL on Saturday. I spent nearly four days (off and on - I have a living to earn as well!) seeking to confirm that this was indeed the infection that killed the unfortunate Mrs Hallapanavar and, specifically, that it was not O104:H4, the strain in the 2011 German outbreak that killed 24 people and infected more than 2400. I wanted to confirm that particularly because O104:H4 deploys a particularly effective 'poison pill' defence: it dies quite readily under attack from antibiotics but, as it dies, cells burst and release intense toxins that overwhelm the body's defence mechanisms. As the standard treatment for a pregnant woman presenting with pains symptomatic of bacterial infection is antibiotics, if it had been O104:H4, the cure would have killed her, very quickly.

Had that been the case then, with years of experience, I would understand the fears that could be found to be leading to a cover-up. But it was not O104:H4, it was an EBSL.

In the course of my investigation I asked some pretty impertinent questions, including enquiries about possible racism and, maybe, cultural influences, including the possibility of procurement of an illegal abortion for the purposes of gender selection. (The racism enquiries were in both directions, btw). I got some pretty strong fleas in my ear for doing so. Like it or not, the suggestion that racism had something to do with the case was rebutted in the strongest possible terms.

I conducted enquiries as exhaustive as they could be, Greg. I did not go off the deep end - I held back from publishing for days in order to confirm what I had been told. I did not (he said, gently) go off down the road that this was about medical incompetence.

Oh, bugger gently. Greg, you talked about medical incompetence in your blog of 14 November. I quote: "... it seems to me that at least on the basis of the facts as reported, this was a straightforward and stomach-churning case of shocking -- possibly even criminal -- medical malpractice with a tragic outcome."

You leaped to medical malpractice; I didn't. I spent days trying to find out what actually happened.

Does that make me a better person than you? I don;t know so I cannot say. All I can say is that I think I have displayed at least as much level-headedness as you accuse Mark Lambert of possessing. In the middle of this firestorm, i went looking for reliable testimony.

I found it, and I also found fear and trepidation. I will not apologise for saying that, because it is the truth. People are concerned. I asked a few days ago why the Irish government had not raised the possibility of incurable infection, a possibility of which I was already aware. I have not had a satisfactory explanation. I have had shrugs and shiftiness, sidelong glances and slippery looks, but no satisfactory explanation.

When I said, If you can't find evidence of a conspiracy then you aren't looking hard enough, it was intended to raise a smile - but a knowing smile, to be a joke 'on the square', if you like. The old idea that once is happenstance, twice is coincidence and thrice is conspiracy may not always be true but it's worth bearing in mind when headline-consuming firestorms erupt. There may very well be no connection at all between Marie Stopes opening a clinic in Northern Ireland; RTE broadcasting an undercover investigation revealing illegal and dangerous practices in advisory services in Ireland; and the fact that a lobby group appears to have had advance notice of this case, as well as access to confidential patient records. In fact, there probably isn't - it's all just coincidence. Forget I mentioned it.

I agree with you that "... pro-choicers shouldn't be jumping to the conclusion that Savita died because she was denied a termination of pregnancy or because of any supposed uncertainty in Irish law,"

And I certainly agree that "...neither should pro-lifers be asserting that she definitely didn't die for those reasons..." That's why I spent days researching and investigating - past the point where I could have sold the story to mainstream media, btw. (I make my living as a freelance journalist so not selling stories or leads causes me physical as well as financial pain).

However, we draw apart when you talk of "...grabbing at the claim that she died because of some subcontinental superbug." "Subcontinental" implies that this strain of e.coli is restricted to, or originated in this case from, India. That is incorrect. A concern among the Irish medics I spoke to is that, far from being restricted to the Subcontinent, this bug has become established in the general public in Ireland. And it isn't a 'superbug' - just an example of evolution at work. There will be many more and we should all be concerned about that reality.

Actually, 'that reality' is my real concern. An informant said to me that they believed it was not a coincidence that the UK's Chief Medical Officer had chosen to release a major statement on antibiotic-resistant infections last week. Did you miss it? Catch up at http://www.dh.gov.uk/health/2012/11/eaad-cmo/

If resistance to antibiotics spreads further into the bacterial field, we will be back to the 1930s. Infections we think of as minor will, once again, be killers. All this stuff about whether the law in Ireland needs to be revised is so much eyewash.

Greg, you got to a truth in your post on 18 November, headlined "paper Doesn't refuse Ink, as my Dad says". A crucial truth was buried in the middle of Kitty Holland's article, to whit: "Whether the fact that Savita had been refused a termination was a factor in her death has yet to be established."

That is a classic 'not me guv' defence: search the article and you will find no absolute accusation that the lack of an abortion killed Mrs Hallapanava; assertions, yes, but you can only find this note of caution where no-one will look for it - except you, to your credit.

You think Kitty Holland has no agenda?

Yes, I am pro-life but I was initially going into this story looking for confirmation of my expectation that it was about medical malpractice and misunderstanding of Cathiolic teaching, as well as irish medical ethics, and that this dreadful coincidence of those two had led to this woman's catastrophic death.

Thanks for this, and to start with I shall amend the text to get your name right. And yes, I don't believe for a moment that you went off on one following Dr Clair's letter; I'd seen a message you'd sent some days ago, and know you've been looking around.

I meant no disrespect to you in this matter, and apologise for any I've caused. My concern, in truth, is less about you than about the likes of Mark and myself, people who are in no position to judge this stuff. Neither medics nor privy to the material you have gathered, we're hardly qualified to assert anything about this; speaking just for myself, I'm habitually loath to repeat something I can't personally substantiate.

I did leap to medical malpractice the other day, and I'm not happy about that as I feel I have cast unfair aspersions on Galway's doctors by doing so. That said, I specifically said that this was merely how things seemed to me, and that my thoughts on the matter were based solely on the facts as initially reported. This was before Praveen changed his story, or RTE published a timeline contesting it in several respects, purporting to come from the hospital.

When you say that the threat to the Irish population is your concern, I hear you. I've written a lot here about the need to take seriously -- and to start by dealing honestly with -- the widespread phenomenon that is child sexual abuse in Ireland, but people almost invariably assume that when I talk about it my aim is to defend the Church. My primary aim is to get people to understand the scale and nature of the problem, and the dynamics and prevalence of denial. And yes, that means people getting to realise that the Church is just one small piece in the puzzle, but my aim is certainly not to write in order to whitewash the Church. I don't think that you've grabbed at things, but I fear that others will grab at what you've said, and do so in a desperate attempt to believe that they're not somehow to blame.

I'd spotted the statement on antibiotics, yes, and have been uneasy with the cluster of stories on this issue in the last few weeks. Since that ludicrous 'March for Choice' things have been all too busy.

Among other things, I'm disappointed that the British Children's Commissioner's report on sexual abuse by gangs has been lost in all the noise of late: between this, Gaza, and the Anglican synod, the rape of thousands upon thousands of British children and teenagers has fallen through the cracks.

Anyway, if you're confident in your work then you should definitely stand by it.

"When you say that the threat to the Irish population is your concern..."

Antibiotic resistance is not restricted to Ireland, Greg; it is a global threat. The Irish have identified that this particular strain of e.coli ESBL is in Ireland's general population; the UK's Chief Medical Officer has also come out with warnings about the gravity of the situation.

I'll stay out of discussing the medical case, as you say we don't know all the facts. But it is interesting to see that people who are pro-life want to insist her death could not have been prevented even if she had been given a termination and the pro-choice say it could have been if she had been given a termination. I don't think we'll ever be able to be 100% certain of the truth there. It seems people who are pro-life like the law at the moment and people who are pro-choice don't.

There is still the issue of the chilling effect http://en.wikipedia.org/wiki/Chilling_effect_(law) of the uncertainty around what doctors can and can't do, that does exist: http://www.irishtimes.com/newspaper/ireland/2012/1117/1224326702078.html

I think both sides can agree people in the medical profession are uncertain. Surely, both sides would like more clarity here?

I think the case itself is a catalyst. No matter what is concluded, it will not in itself change anything.

Maybe her death was inevitable, maybe it was an honest mistake, maybe it was malpractice, maybe it was the chilling effect of an ambiguous legal situation. All are possibilities. Maybe it was a mix of all of those.

There are people who think there is no need to change the law or medical policies on when and how to terminate a fetus. There are people who think there may be need for some change, but things are basically OK. Then there are others who think we are far behind the realities of what is required legally. I am in the that group.

I remember when I was about 15 in 1983 when the abortion referendum took place. I was too young to have a say, and just remember thinking abortion was just killing unborn babies. I knew nothing of the suffering banning it caused women.

The thing is, the majority of adults in Ireland then where very conservative and followed the church's line closely. As it happened, since only 50% of the electorate actually voted, those that did 2/3 voted for it. Hardly a landslide.

So, anyone born since 1966 hasn't had a vote or a say on this. That is now more than half of the voting population. That is my generation, and if this case has shown anything, it is that there are a great many people in Ireland and the rest of the world that think we have to catch up in relation to our laws on abortion.

What really matters is what happens in the Dáil I think. This case has just shown how much of a need for change there is.

I flit between Ireland and England, skulking round churches, libraries, and museums, wetting my throat rather less often than I’d like, but perhaps more often than I should.
I suspect that the secret of life lies in laughter and humility, that only living things can go against the stream, that the riddles of God are more satisfying than the solutions of man, and that placed as sentinels of an unknown watch, we have a duty to whistle.
I think even more than I talk, and on good days I do so in that order.